mri in cervix and endometrial cancer · carcinoma of the cervix • stage of disease has a profound...
TRANSCRIPT
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MRI in Cervix and Endometrial
Cancer
Dr Sarah Swift
St James’s University Hospital
Leeds, UK
28th Congress of the
Hungarian Society of
Radiologists
RCR Session
Budapest June 2016
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Objectives
• Cervix and endometrial cancer
– What it looks like on MRI
• What matters
– To the surgeon
– To the clinical oncologist
– To the radiologist!
– To the patient!!
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Carcinoma of the Cervix
• Traditionally…
• FIGO Staging System
based on clinical
examination
• Introduced in 1928
• 8 revisions since
• Most recently 2009
• But…
• Inaccurate
• Clinical staging errors in
up to 25% of Stage I and
Stage II disease
• Up to 67% in Stage II –
IV
• Underestimation in 25 –
67%
• Overestimation in 2%
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Carcinoma of the Cervix
• Stage of disease has a
profound influence on
treatment options
available to the patient
• Fertility sparing vs.
radical surgery
• Surgical vs. non-surgical
management
• Radical vs. palliative
intent
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MRI and Carcinoma of the Cervix
• Established evidence
base for the use of MRI
• Provides sufficient
information for
management decision
making
• Revised FIGO staging –
influenced by imaging
findings
• Accuracy• Subak L et al. Obstet Gynecol
1995;86:43-39
• Cost effective• Hricak H et al. Radiology
1996;198:403-409
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2009 FIGO Staging
Stage I Tumour confined to cervixIA Micro invasiveIB Clinically invasive
Stage II tumour extension beyond cervix but not to pelvic sidewallIIA involvement of
upper 2/3rds ofvagina
IIB parametrial invasion
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MRI and Gynaecological malignancy
• Inherent soft tissue
contrast of T2W MRI
• See intrinsic
anatomy of uterine
body and cervix
• Identify pathology
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MRI and Carcinoma of the Cervix
• Increased fibrous tissue
in the normal cervical
stroma
• Lower signal intensity
than myometrium on
T2W
• Tumour visible as
increased SI against the
low SI stroma
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MRI and Carcinoma of the Cervix
• Increased fibrous tissue
in the normal cervical
stroma
• Lower signal intensity
than myometrium on
T2W
• Tumour visible as
increased SI against the
low SI stroma
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MRI and Carcinoma of the Cervix
• Squamous carcinoma
occurs at the squamo-
columnar junction
• Pre-menopausal
women – at the level of
the ectocervix
• Tumours often
exophytic
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MRI and Carcinoma of the Cervix
• Post menopausal status
• Junction migrates up
the endocervical canal
• Tumours grow
superiorly into the
uterine body
• May obstruct the
endometrial cavity
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MRI and Carcinoma of the Cervix
• Post menopausal status
• Junction migrates up
the endocervical canal
• Tumours grow
superiorly into the
uterine body
• May obstruct the
endometrial cavity
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What information is needed from MRI
in Cervical Cancer?
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? Surgery - 1
• Is the disease confined
to the cervix?
• Avoid inappropriate
surgery for advanced
disease
• Not deny suitable
patients curative
surgical option
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? Surgery - 1
• Is the disease confined
to the cervix?
• Is there an intact
stromal ring?
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• Intact stromal ring
• Negative predictive value
• Intact stromal ring has a high (95%) negative predictive value for parametrial invasion
– Subek LL et al, ObstetGynecol 1995
? Surgery - 1
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? Surgery - 2
• Tumour size?
• Independent poor
prognostic factor
– Failure of local disease
control with increasing
tumour size
– Perez CA et al. Cancer; 1992:
2796-2806
• MRI can give an
accurate assessment of
tumour dimensions and
volume
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? Surgery - 2
• Tumour size
• Independent poor
prognostic factor
• Recognised in new FIGO
Staging
• Stage IB – clinically
visible lesion
– IB1 - < 4cm
– IB2 - > 4cm
• Stage IIA FIGO 2009
– IIA1 - < 4cm
– IIA2 - > 4cm
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? Surgery - 3
• Are there nodal
metastases?
• Not included in FIGO
staging
• Profound influence on
treatment strategy
• Poor prognostic factor
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Nodal disease
• MRI = CT
• Accuracies ~ 85 – 90%
• Low sensitivity 43 –
73%
• Inability to identify
metastases in normal
sized nodes
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Nodal disease
• Size
• Other features
– Extracapsular
extension
– Central necrosis
• Obstruction
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Nodal disease
• Size
• Other features
– Extracapsular
extension
– Central necrosis
• Obstruction
• PET CT
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Non-surgical management
• Chemo-radiotherapy
• Concurrent
chemotherapy and
external beam
radiotherapy
• 3 x intracavitary
brachytherapy
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Non-surgical management
• Aim to deliver a
tumouricidal dose of
radiation to a well
defined target volume
• Spare surrounding
normal tissue
• Curative or palliative
intent
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Radiotherapy Volumes
CTV
PTVGTV
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GTVCTV
PTV
Irradiated Volume
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External Beam Radiotherapy
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What does the Radiation Oncologist
want to know - 1
• Anatomical detail
• Where exactly is the
tumour?
– Accurate delineation of
the GTV
• CT planned
• Need bony and tissue
electron density
information
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What does the Radiation Oncologist
want to know - 2
• Tumour size
• Particularly
craniocaudal extent
• Planning intracavitary
treatment
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What does the Radiation Oncologist
want to know - 2
• Tumour size
• Particularly
craniocaudal extent
• Planning intracavitary
treatment
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What does the Radiation Oncologist
want to know - 3
• Is there vaginal
involvement
• What is the inferior
extent?
• Affects RT volumes
– GTV and CTV
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What does the Radiation Oncologist
want to know - 3
• Is there vaginal
involvement
• What is the inferior
extent?
• Affects RT volumes
– GTV and CTV
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What does the Radiation Oncologist
want to know - 4
• Where are the nodal
metastases?
• Significant impact on management planning
• Nodal GTV and CTV
• Node negative on MR -external iliac level ~ L5/S1
• Node positive - one level above the positive nodes
• Inguinal nodes if macroscopic lesion in lower third of the vagina
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MRI and Carcinoma of the Cervix
• Central role in patient assessment
• In most patients, in conjunction with clinical status, MRI alone provides sufficient information for decisions to be made about case management
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MRI and Endometrial Cancer
• More contentious than
the use of MRI in
Cervical Cancer
• Surgery is the primary
treatment modality
• Extent of surgery
depends on pathology
and tumour stage
• Grade 1& 2, stage 1A
disease
– Hysterectomy
• Grade 3 all stages and
Grade 1 & 2 stage > 1B
– Lymphadenectomy
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MRI and Endometrial Cancer
• Why?
• Stage disease
• Select patients who at
risk of relapse for more
radical surgery
• Plan adjuvant treatment
• Avoid over treating low-
risk patients
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MRI and Endometrial Cancer
• Depth of myometrialinvasion
– Prognostic information
• Correlates
– Tumour grade
– Cervix involvement
– Likelihood of nodal metastases
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How good is MRI for assessing depth of
invasion?
• Radiology literature
reports accuracy between
55 – 77% for T2W images
• 85 – 91% for dynamic
contrast enhanced images
– Kinkel K et al Radiology
1999
– Frei K et al Radiology 2000
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Involvement of the Cervix
• Reported accuracy of
MRI in detecting cervical
invasion – up to 92%
• Sensitivities of 75 – 80%
• Specificities of 94 – 96%
• Adjuvant RT
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Peritoneal disease
• Not a
contraindication to
surgery
• Identify preoperatively
• Need
chemotherapy
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Uterine Dimensions
• Assess suitability for
laparoscopically assisted
vaginal hysterectomy (LAVH)
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Limitations of MRI
• Myometrial thinning
by bulky tumours
• Cornual regions
• Coexisting benign
pathology
• Difficult to assess
depth of invasion
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Coexisting benign pathologies
• Adenomyosis
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Coexisting benign pathologies
• Cystic Adenomyosis
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Coexisting benign pathologies
• Leiomyomata
• Distort uterine
anatomy
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What do we want the Surgeons and
Oncologists to know?!
• Heterogeneous
polypoid mass on
T2W images
• Progressive
enhancement post
contrast
• Think sarcoma
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What do we want the Surgeons and
Oncologists to know?!
• Lesions which
prolapse down into
the cervix and vagina
• Uterine inversion
• Think sarcoma
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MRI for Cervix and Endometrial
Cancers
• Demonstrates and
stage the disease
• Can answer the
questions that are
needed to plan
patient management
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Thank you